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Home , Endothrix, Tinea capitis

British Journal of Dermatology 2000; 143: 53±58.

Guidelines for the management of

E.M.HIGGINS,*² L.C.FULLER* AND C.H.SMITH³ *King's College Hospital, London SE5 9RS, U.K. ²Orpington Hospital, Kent BR6 9SU, U.K. ³Lewisham Hospital, London SE13 6LH, U.K. Accepted for publication 15 April 2000

Summary These guidelines for the management of tinea capitis have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. Key words: guidelines, tinea capitis

Disclaimer prevalence has recently been reported in urban areas, particularly in children of Afro-Caribbean These guidelines have been prepared for dermatologists extraction.1±3 The main pathogens are anthropophilic on behalf of the British Association of Dermatologists organisms with tonsurans now accounting and reflect the best data available at the time the report for . 90% of cases in the U.K. and North America.2,4,5 was prepared. Caution should be exercised in inter- These infections frequently spread among family preting the data; the results of future studies may members and classmates.5,6 Certain hairdressing require alteration of the conclusions or recommen- practices such as shaving of the , plaiting or the dations in this report. It may be necessary or even use of oils may promote disease transmission, but desirable to depart from the guidelines in the interests their precise role remains the subject of study. In non- of specific patients and special circumstances. Just as urban communities, sporadic infections acquired from adherence to the guidelines may not constitute defence puppies and kittens are due to M. canis, which, against a claim of negligence, so deviation from them however, accounts for less than 10% of cases in the should not necessarily be deemed negligent. U.K. Occasional infection from other animal hosts (e.g. T. verrucosum from cattle) occur in rural areas. Definition Tinea capitis is an infection caused by Pathogenesis fungi (usually species in the genera and Trichophyton) of scalp hair follicles and the surrounding There are three recognized patterns: , skin. ectothrix and . The latter, a pattern of caused by T. schoenleinii, is rarely seen in the U.K. being Epidemiology largely confined to eastern Europe and Asia and is not considered further here. Endothrix infections are Tinea capitis is predominantly a disease of preado- characterized by arthroconidia (spores) within the lescent children, adult cases being rare.1 Although hair shaft. The cuticle is not destroyed. Ectothrix world-wide in distribution, its prevalence in the U.K. infections are characterized by hyphal fragments and has been relatively low in the past. An increase in arthroconidia outside the hair shaft, which leads eventually to cuticle destruction.

These guidelines were commissioned, developed and edited by the Therapy Guidelines and Audit Sub-Committee of the British Association of Dermatologists, C.E.M.Griffiths (Chairman), A.V.Anstey, Clinical diagnosis of scalp ringworm C.B.Bunker, N.H.Cox, K.L.Dalziel, M.R.Judge, H.C.Williams, D.K.Metha and S.M.Burge. These guidelines are planned to be A variety of clinical presentations are recognized as updated by January 2001. being either inflammatory or non-inflammatory and q 2000 British Association of Dermatologists 53 54 E.M.HIGGINS et al.

Table 1. Summarizing the clinical patterns of tinea capitis Clinical patterns Clinical description Differential diagnosis Diffuse scale Generalized diffuse scaling of the scalp Seborrhoeic and , Grey patch Patchy, scaly alopecia Seborrhoeic and atopic dermatitis, psoriasis Black dot Patches of alopecia studded with broken-off hair stubs , Diffuse pustular Scattered pustules associated with alopecia scaling ^ associated Bacterial , dissecting folliculitis lymphadenopathy Boggy tumour studded with pustules ^ associated lymphadenopathy , neoplasia are usually associated with patchy alopecia (Table 1). Microscopy and culture However, the infection is so widespread, and the clinical Samples should be sent to laboratories with a particular appearances can be so subtle, that in urban areas, tinea interest and expertise in mycology. capitis should be considered in the diagnosis of any Microscopy provides the most rapid means of child over the age of 3 months with a scaly scalp, until diagnosis, but is not always positive. Scalp scales and dismissed by negative mycology. Infection may also be broken off hair stumps containing the root section associated with painful regional lymphadenopathy, (rather than intact ) are mounted in a 10±30% particularly in the inflammatory variants. A general- potassium hydroxide solution and viewed under the ized eruption of itchy particularly around the light microscope. Positive microscopy (when the hairs outer helix of the ear may occur as a reactive or scales are seen to be invaded by spores or hyphae) phenomenon (an `id' response). This may start with confirms the diagnosis and allows treatment to the introduction of systemic therapy and so be commence at once. mistaken for a drug reaction. Scales, hairs or samples obtained with a sterile single use brush are often not suitable for microscopy, but are inoculated on to a suitable culture medium, e.g. Laboratory diagnosis of scalp ringworm Sabouraud's. Culture allows accurate identification of the organism involved, and this may alter the treat- If tinea capitis is suspected, specimens should be taken ment schedule. Culture is more sensitive than micro- to confirm the diagnosis as systemic therapy will be scopy; results may be positive even when microscopy is required. negative, but may take up to 4 weeks to become available. Conventional sampling of a kerion can be difficult. In these cases negative results are not uncommon and the Taking specimens diagnosis and decision to treat may need to be made Affected areas should be scraped with a blunt scalpel to clinically. A moistened standard bacteriological swab harvest affected hairs, broken-off hair stubs and scalp taken from the pustular areas and inoculated on to the 8 scale. This is preferable to plucking, which may remove culture plate may yield a positive result. uninvolved hairs. Scrapings should be transported in a folded square of paper preferably fastened with a paper Wood's light examination clip, but commercial packs are also available (e.g. Dermapak, Dermaco, Toddington, Bedfordshire, U.K. This is useful for certain ectothrix infections, e.g. those and Mycotrans, Biggar, Lanarkshire, U.K.). It is easier to caused by M. canis, M. rivalieri and M. audouinii, which see affected hairs on white paper rather than black. cause the hair to fluoresce bright green. However, as Alternatively, the area can be rubbed with a moistened most of the current infections in the U.K. are endothrix gauze swab7,8 or brushed gently 10 times with a and so negative under Wood's light, it is of limited value plastic, sterile, single use toothbrush [BR8 (unpasted), for screening and monitoring these infections. Brushaway Products, Chislehurst Railway Station, Station Approach, Chislehurst, Kent BR7 5NN, U.K.]. Therapy of tinea capitis The brush can then be sent in the container provided to the laboratory for culture.9 (Strength of recom- The aim of treatment is to achieve a clinical and mendation A; quality of evidence III.) mycological cure as quickly as possible. Oral ˆ q 2000 British Association of Dermatologists, British Journal of Dermatology, 143,53±58 GUIDELINES FOR THE MANAGEMENT OF TINEA CAPITIS 55

Table 2. Dosing regimen for tinea capitis Drug Current standard dose Duration 10±25 mg/kg daily taken with food divided dose 8±10 weeks , 20 kg 62´5 mg od: . 20 , 40 kg 125 mg od: . 40 kg 250 mg od 4 weeksa 5 mg/kg per day 1±4 weeks a Longer for Microsporum infections. therapy is generally needed.10 (Strength of recom- Contra-indicated in erythematosus, porphyria mendation A; quality of evidence IIi.) and severe liver disease. ˆ Drug interactions. Include warfarin, cyclosporin and Topical the oral contraceptive pill. Topical treatment alone is not recommended for the Terbinafine. This acts on fungal cell membranes and is management of tinea capitis.10 (Strength of recom- fungicidal. It is effective against all . It is mendation A; quality of evidence III.) It may how- ˆ ˆ not yet licensed for tinea capitis, although a licence for ever, reduce the risk of transmission to others in the children of . 2 years is being considered. It is at least early stages of systemic treatment. (Strength of recom- as effective as griseofulvin and is safe for the manage- mendation B; quality of evidence IIii.) Selenium ˆ ˆ ment of scalp ringworm due to Trichophyton sp. in sulphide11 and povidone iodine12 shampoos, used children.15±17 Its role in management of Microsporum twice weekly, reduce the carriage of viable spores and sp. is debatable.18 Early evidence suggests that higher are assumed to reduce infectivity. doses or longer therapy (. 4 weeks) may be required in microsporum infections.19,20 Dosage depends on the Oral weight of the patient, but lie between 3 and 6 mg/kg Griseofulvin. This is fungistatic, and inhibits nucleic acid per day (see Table 2). Side-effects include; gastro- synthesis, arresting cell division at metaphase and intestinal disturbances and in 5% and 3% of cases, respectively.21 (Strength of recommendation impairing fungal cell wall synthesis. It is also anti- ˆ A/B; quality of evidence I/IIi.) inflammatory. It remains the only licensed treatment ˆ for scalp ringworm in U.K. It is available in tablet or Advantages. Fungicidal so shorter therapy required suspension form. The recommended dose, for those (cf. griseofulvin) so increased compliance more likely. older than 1 month is 10 mg/kg per day. Taking the Disadvantages. No suspension formulation and no drug with fatty food increases absorption and aids U.K. licence for tinea capitis. bioavailability.13,14 Dosage recommendations vary Drug interactions. Plasma concentrations are reduced according to the formulation used, with higher doses by rifampicin and increased by cimetidine. being recommended by some authors for micronized griseofulvin as opposed to ultramicronized griseofulvin, Itraconazole. Itraconazole exhibits both fungistatic and but up to 25 mg/kg may be required. The duration of fungicidal activity depending on the concentration of therapy depends on the organism (e.g. T. tonsurans drug in the tissues, but like other azoles, the primary infections may require prolonged treatment schedules) mode of action is fungistatic, through depletion of cell but varies between 8 and 10 weeks. (Strength of membrane ergosterol, which interferes with membrane recommendation A; quality of evidence IIii.) Shorter permeability. 100 mg/day for 4 weeks or 5 mg/kg per ˆ ˆ courses may lead to higher relapse rates. day in children is as effective as griseofulvin22 and Side-effects include nausea and rashes in 8±15%. terbinafine.23 (Strength of recommendation B; quality ˆ The drug is contra-indicated in pregnancy and the of evidence I.) Small studies suggest that shorter or ˆ manufacturers caution against men fathering a child pulsed regimens may also be effective.24 (Strength of for 6 months after therapy. (Strength of recom- recommendation B; quality of evidence I.) Itra- ˆ ˆ mendation B; quality of evidence III.) conazole is currently unlicensed in the U.K. for use in ˆ ˆ Advantages. Licensed; inexpensive; syrup formulation tinea capitis and for use in children and there are no is more palatable; suspension allows accurate dosage plans to change this. adjustments in children; and extensive experience. Advantage. Pulsed shorter treatment regimens are Disadvantages: Prolonged treatment required. possible. q 2000 British Association of Dermatologists, British Journal of Dermatology, 143,53±58 56 E.M.HIGGINS et al.

Disadvantage. Lack of U.K. licence to treat tinea capitis Cleansing of fomites. Viable spores have been isolated and possible side-effects. Potential drug interactions. from hairbrushes and combs. For all anthropophilic More studies needed to confirm paediatric require- species these should be cleansed with disinfectant.28 ments. (Strength of recommendation B; quality of evidence ˆ ˆ Drug interactions. Enhanced toxicity of anticoagulants IV.) Proprietary phenolic disinfectants are no longer (warfarin), antihistamines (terfenadine and astemi- available, but simple bleach or Milton should be zole), antipsychotics (sertindole), anxiolytics (mida- suitable alternatives. (Strength of recommendation B; ˆ zolam), digoxin, cisapride, cyclosporin and simvastatin quality of evidence III.) ˆ (increased risk of myopathy). Reduced efficacy of itraconazole with concomitant use of H2-blockers, phenytoin and rifampacin. Soaking off crust from or pustules. This is recommend by some authors. Although this is not 29 . Has occasionally been assessed for tinea necessary, it is often soothing. (Strength of recom- mendation C; quality of evidence III.) capitis but its use has mainly been limited by side- ˆ effects. Doses of 3±5 mg/kg per day for 4 weeks are 25 effective in children with tinea capitis. There are no Steroids. The use of corticosteroids (both oral and large published series of its use and it is not licensed for topical) for inflammatory varieties, e.g. kerions and the treatment of tinea capitis in the U.K. (Strength of severe id reactions is controversial, but may help to recommendation C; quality of evidence I.) 30 ˆ ˆ reduce itching and general discomfort. Although in the past steroids have been thought to minimize the Ketoconazole. Has occasionally been assessed for tinea risk of permanent alopecia secondary to scarring, capitis but its use has mainly been limited by side- current evidence does not suggest any reduction in effects. Doses of between 3´3 and 6´6 mg/kg per day. clearance time compared with griseofulvin alone.29,30 Resolution is comparable with griseofulvin but the (Strength of recommendation C; quality of evidence I.) response may be slower. However, side-effects are ˆ ˆ arguably sufficiently significant to lead to the recom- mendation by some authors that it should not to be Treatment failures used in children.26 Studies have not shown it to be consistently superior to griseofulvin and its use in Some individuals are not clear at follow-up. The children is limited by . Not licensed for reasons for this include: the treatment of tinea capitis in the U.K. (Strength of 1 Lack of compliance with the long courses of recommendation D; quality of evidence I.) ˆ ˆ treatment. 2 Suboptimal absorption of the drug. Additional measures 3 Relative insensitivity of the organism. 4 Reinfection. Exclusion from school. Although there is a risk of the transmission of infection from patients to unaffected T. tonsurans and Microsporum sp. are typical culprits in class-mates, for practical reasons children should be persistently positive cases. If fungi can still be isolated allowed to return to school once they have been at the end of treatment, but the clinical signs have commenced on appropriate systemic and adjuvant improved, the authors recommend continuing the topical therapy.3,12 (Strength of recommendation B; original treatment for a further month. ˆ quality of evidence IIiii.) If there has been no clinical response and signs persist at the end of the treatment period, then the Familial screening. Index cases due to the anthro- options include: pophilic T. tonsurans are highly infectious. Family 1 Increase the dose or duration of the original members27 as well as other close contacts should be drug: both griseofulvin (in doses up to 25 mg/kg screened (both for tinea capitis and corporis) and for 8±10 weeks) and terbinafine have been used appropriate mycological samples taken preferably successfully and safely at higher doses or for longer using the brush technique, even in the absence of courses to clear resistant infections. (Strength of clinical signs. (Strength of recommendation B; quality recommendation C; quality of evidence IV.) ˆ ˆ ˆ of evidence III.) 2 Change to an alternative antifungal, e.g. switch from ˆ q 2000 British Association of Dermatologists, British Journal of Dermatology, 143,53±58 GUIDELINES FOR THE MANAGEMENT OF TINEA CAPITIS 57

griseofulvin to terbinafine or itraconazole. (Strength 7 Borchers SW. Moistened gauze technique to aid diagnosis of tinea of recommendation C; quality of evidence IV.) capitis. J Am Acad Dermatol 1985; 13: 672±3. ˆ ˆ 8 Head ES, Henry JC, Macdonald EM. The cotton swab technique for the culture of dermatophyte infectionsÐits efficacy and Carriers merit. J Am Acad Dermatol 1984; 11: 797±801. 9 Fuller LC, Child FJ, Midgely G, Hay RJ, Higgins EM A practical The optimal management of symptom-free carriers (i.e. method for mycological diagnosis of tinea capitis: validation of the individuals without overt clinical infection, but who are toothbrush technique. J Eur Acad Dermatol Venereol 1997; 9 culture positive) is unclear. In those with a heavy (Suppl. 1): S209. growth/high spore count on brush culture, systemic 10 Elewski BE. Cutaneous mycoses in children. Br J Dermatol 1996; 134 (Suppl.46): 7±11. antifungal therapy may be justified as these individuals 11 Allen HB, Honig PJ, Leyden JJ, McGinley KJ. Selenium sulphide: are especially likely to develop an overt clinical adjunctive therapy for tinea capitis. Pediatrics 1982; 69:81±3. 3 infection, are a significant reservoir of infection and 12 Neil G, Hanslo D. Control of the carrier state of scalp are unlikely to respond to topical therapy alone.5,31 dermatophytes. Pediatr Infect Dis J 1990; 9:57±8. Alternatively, they may represent a missed overt 13 Anonymous. Alder Hey Book of Children's Doses, 6th edn. Liverpool: Royal Liverpool Children's Hospital Academy, 1994 clinical infection. For those with light growth/low 14 Crounse RG. Human pharmacology of Griseofulvin: the effect of spore counts on brush culture, twice weekly selenium fat intake on gastrointestinal absorption. J Invest Dermatol 1961; sulphide or povidone iodine shampoo is probably 37: 529±33. adequate.11,12 (Strength of recommendation B; quality 15 Hussain H. Randomised double blind controlled comparative ˆ of evidence IV.) study of terbinafine versus griseofulvin in tinea capitis. J Dermatol ˆ Treat 1995; 6: 167±9. 16 Jones TC. Overview of the use of terbinafine (Lamisil) in children. Follow-up Br J Dermatol 1995; 132: 683±9. 17 Filho ST, Cuce LC, Foss NT, Marques SA, Santamaria JR. Efficacy, The definitive end-point for adequate treatment is not safety and tolerability of terbinafine for tinea capitis in children: clinical response but mycological cure; therefore, Brazilian multicentric study with daily oral tablets for, 1, 2 and 4 follow-up with repeat mycology sampling is recom- weeks. J Eur Acad Dermatol Venereol 1998; 11: 141±6. mended at the end of the standard treatment period 18 Baudrez-Rosselet F, Monod M, Jaccoud S, Frenk E. Efficacy of terbinafine treatment of tinea capitis in children varies and then monthly until mycological clearance is according to the dermatophyte species. Br J Dermatol 1996; documented. (Strength of recommendation A.) Treat- 135: 1011±12. ˆ ment should, therefore, be tailored for each individual 19 Mock M, Monod M, Baudraz-Rosselet F, Panizzon RG. Tinea patient according to response. capitis dermatophytes: susceptibility to antifungal drugs tested in vitro and in vivo. Dermatology 1998; 197(4): 361±7. 20 Bruckbauer HR, Hofman H. Systemic antifungal treatment of Acknowledgments children with terbinafine. Dermatology 1997; 195: 134±6. 21 O'Sullivan DP, Needham CA, Bangs A et al. Post marketing Thanks to G.Midgley for advice on mycology. surveillance of oral terbinafine in UK. report of large cohort study. Br J Clin Pharmacol 1996; 42: 559±65. References 22 Lopez Gomez S, Del-Palacio A, Van-Cutsem J et al. Itraconazole verses Griseofulvin in the treatment of tinea capitis: a double 1 Bronson DM, Desai DR, Barsky S, McMillen Foley S. An epidemic blind randomized study in children. Int J Dermatol 1994; 33(10): of infection with revealed in a 20-year 743±7. survey of fungal infections I Chicago. J Am Acad Dermatol 1983; 8: 23 Jahangir M, Hussain I, Ul Hasan M, Haroon TS. A double- 322±30. blind randomized comparative trial of itraconazole versus 2 Fuller LC, Child FC, Higgins EM. Tinea capitis in southeast terbinafine for 2 weeks in tinea capitis. Br J Dermatol 1998; London: an outbreak of Trichophyton tonsurans infection. Br J 139: 672±4. Dermatol 1997; 136: 139. 24 Gupta AK, Alexis ME, Raboobee N et al. Itraconazole pulse 3 Hay RJ, Clayton YM, de Silva N, Midgley G, Rosser E. Tinea capitis therapy is effective in the treatment of tinea capitis in children: an in south east LondonÐa new pattern of infection with public open multicentre study. Br J Dermatol 1997; 137: 251±4. health implication. Br J Dermatol 1996; 135: 955±8. 25 Solomon BA, Collins R, Sharma R et al. Fluconazole for the 4 Leeming JG, Elliott TSJ. The emergence of Trichophyton tonsurans treatment of tinea capitis in children. J Am Acad Dermatol 1997; tinea capitis in Birmingham, U.K. Br J Dermatol 1995; 133: 37: 274±5. 929±31. 26 Gan VN, Petruska M, Ginsburg CM. Epidemiology and treatment 5 Williams JV, Honig PJ, McGinley KJ, Leyden JJ. Semiquantitative of tinea capitis. ketoconazole vs griseofulvin. Paediatr Infect Dis J study of tinea capitis and asymptomatic carrier state in inner-city 1987; 6:46±9. school children. Pediatrics 1995; 96: 265±7. 27 Babel DE, Baughman SA. Evaluation of the adult carrier state in 6 Kligman AM, Constant ER. Family epidemic of tinea capitis due to juvenile tinea capitis caused by Trichophyton tonsurans. J Am Acad Trichophyton tonsurans (variety sulfureum). Arch Dermatol 1951; Dermatol 1989; 21: 1209±12. 63: 493±9. 28 Mackenzie DWR. Hairbrush diagnosis in detection and q 2000 British Association of Dermatologists, British Journal of Dermatology, 143,53±58 58 E.M.HIGGINS et al.

eradication of non-fluorescent scalp ringworm. Br Med J 1963; E There is good evidence to support the rejection of the 10: 363±5. use of the procedure. 29 Anonymous. Management of scalp ringworm. Drug Ther Bull 1996 Jan; 34 (1): 5±6. 30 Honig PJ, Caputo GL, Leyden JJ, McGinley K, Selbst SM, Quality of evidence McGravey AR. Treatment of kerions. Pediatr Dermatol 1994; 11: 69±71. I Evidence obtained from at least one properly 31 Midgley G, Clayton YM. Distribution of dermatophytes and designed, randomized control trial. candida spores in the environment. Br J Dermatol 1972; 86: II-i Evidence obtained from well designed, controlled 69±77. trials without randomization. II-ii Evidence obtained from well designed cohort or case±control analytical studies, preferably from more than one centre or research group. Appendix II-iii Evidence obtained from multiple time series with or without the intervention. Dramatic results in Strength of recommendations uncontrolled experiments (e.g. the introduction of A There is good evidence to support the use of the penicillin treatment in the 1940s) could also be procedure. regarded as this type of evidence. B There is fair evidence to support the use of the III Opinions of respected authorities based on clinical procedure. experience, descriptive studies or reports of expert C There is poor evidence to support the use of committees. the procedure. IV Evidence inadequate owing to problems of D There is fair evidence to support the rejection of methodology (e.g. sample size, length or compre- the use of the procedure. hensiveness of follow-up or conflicts of evidence)

q 2000 British Association of Dermatologists, British Journal of Dermatology, 143,53±58